Tuesday, November 13, 2012

One of the most difficult situations a Rabbi enters is the "end of life"/"quality of life" debate.

* Families can be torn apart as they debate the patient's best interests and preferences;

* Doctors are conflicted between their mission of preserving life, their responsibility to the overall healthcare system, and their personal feelings about the patient's state and prospects;

* Rabbis don't know which way to turn.

One of the hardest such cases is the persistent vegetative state. In many cases the doctors aver that the patient has no consciousness and will never have any consciousness. Family members might interpret certan physical movements as signs of consciousness, while medical staff will explain those movements in other ways. Everyone will debate what the patient wanted, or would have wanted. And various players will point to the cost of maintaining healthcare, insisting that there is no point in persisting - while traditional halachah insists that we are obligated to provide certain basic elements so long as we are not prolonging a painful death.

One of the critical questions involved, and perhaps the most critical, is this: Is the patient conscious?

As of this moment, CNN.com and NYtimes.com have not picked this up - but they will, it was only published 24 minutes ago:

Essentially, his brain is doing the talking for him, say leading scientists at the University of Western Ontario’s Brain and Mind Institute.

As a result of breakthrough work on brain activity, the 39-year-old motor vehicle accident victim from London, Ont. has responded to a series of questions, including letting researchers know that he is not in pain.

“It became very clear that Scott had some awareness and he could respond in the scanner to the task we asked him to do while he was in there,” British neuroscientist professor Adrian Owen, who leads the research team, told the Toronto Star Tuesday.

“What we have done here for the very first time is ask a patient a question that is actually relevant to their clinical care.

“Asking somebody whether they are in pain in tremendously important, because of course if the answer had been yes, we could do something,” he said.

Owen said there is no doubt that being able to communicate in this way with a person thought to be a vegetative state is a first and it is hoped will lead to routine communications with at least one in five people in this uncommunicative state.

“That’s where we are trying to get to. We are trying to create what’s called a brain computer interface … some form of a machine that could allow somebody like Scott to routinely communicate with the outside word . . . We would like to give these patients a voice to enable them to actually communicate their wishes and needs,” he told the Star.

By using a functional magnetic imaging procedure he said they can tell by how different parts of Routley’s brain light up that he is responding to suggestions and questions.

“We put him in an MRI scanner and while he is in the scanner we ask him to imagine doing certain things in his mind . . . for example, we ask him to imagine using his arms. Scott is unable to use his arms in reality but it turns out he is perfectly able to imagine moving his arms. And we can pick that up on the scanner and we can tell he’s doing what we ask him to do,” Owen said.

The professor noted in an earlier interview with the Star that while functional magnetic resonance imaging machines, or fMRI images are the gold standard, they are expensive — machines can cost up to $2 million — and it is both costly and disruptive to move patients to the scanners in hospitals.

Owens says it’s quite possible that a portable high-end EEG machine, costing about $75,000, can be used at a patient’s bedside. An EEG uses scalp electrodes to measure the electrical signals coming from neurons in the brain.

Owen said command-following is a routine method of telling if a person is conscious and aware, “and with Scott we can tell he is activating his brain when we ask him to do so.”

“And when we say ‘now stop doing that imagining’ and then we see the little blob in the brain disappear. But when we say start it again now the blob lights up again,” he said.

Owen said Routley on two occasions through a series of question and commands “responded that he wasn’t in any pain.”

This research also raises ethical questions about whether these patients, once they are able to communicate, should be able to direct their care — and the end of their lives.